Huda Fatima

Endosulfan poisoning: An overview

Endosulfan, an organochlorine (OC) insecticide, is a widely used agricultural pesticide, despite its life threatening toxic effects. In this review, the pharmacokinetics of endosulfan, mechanism of endosulfan toxicity, clinical presentations and management, histopathological findings, and toxicological analysis are described, in addition to its environmental toxicity. The toxic effects of endosulfan can affect many organs and systems presenting in a wide array of signs and symptoms. Although termed a restricted OC-classed pesticide, it continues to be used, especially in the developing world, owing to its beneficial effects on agriculture. Several cases of endosulfan poisoning have been reported from different regions of the world. Whether accidental or intentional, endosulfan ingestion proves to be fatal unless immediate, aggressive treatment is initiated. Management is mainly supportive as no antidote exists for endosulfan poisoning as yet. The use of endosulfan needs to be strictly regulated and eventually banned worldwide altogether to lower the current morbidity and mortality resulting from this pesticide. Additionally, monitoring biological samples, using non-invasive techniques such as breast milk sampling, can provide an effective method of observing the elimination of this environmentally persistent organic pollutant from the general population.

Gastrointestinal causes of sudden unexpected death: A review

Gastrointestinal conditions are a less common cause of sudden unexpected death when compared to other conditions such as cardiovascular conditions, but they are equally important. Various congenital and acquired gastrointestinal conditions that have resulted in sudden unexpected death are discussed. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, have been described. Through this article, we aim to highlight the need for physicians to prevent death in such conditions by ensuring that subclinical cases are diagnosed correctly before it is too late and by providing timely and efficacious treatment to the patient concerned. In addition, this review would certainly benefit the forensic pathologist while dealing with cases of sudden unexpected death due to gastrointestinal causes. This article is a review of the major gastrointestinal causes of sudden unexpected death. In addition, related fatal cases encountered occasionally in forensic autopsy practice are also included. There are several unusual and rare causes of life-threatening gastrointestinal bleeding that may lead to sudden unexpected death to cover all the entities in detail. Nevertheless, this article is a general guide to the topic of gastrointestinal causes of sudden unexpected death.

Police officers gunned down while protecting vaccination workers in Pakistan.

The polio vaccination drive in Pakistan has seen umerous obstacles over the years which have all esulted in a failure of complete polio eradication rom the country. Parental refusal to administer accine, religious misconceptions, security lapses or polio workers and ineffective vaccines have all umulatively impeded the success of the vacciation drive [1—3]. Previously, only polio vaccine orkers have been targeted by militant groups but n recent years there has been a paradigm shift in he strategy of the militants towards law enforceent agencies. On 20th April 2016, seven police officers were illed by eight gunmen while guarding health workrs who were administering polio vaccinations in arachi, Pakistan [4]. The officers were killed in wo separate attacks in the Orangi area of Karachi. n the first attack, eight men on motorcycles open red and killed three policemen who were protecing the health workers. The same men later fired at our policemen in a police van who were at a short istance away from the first attack. As a result, the nti-polio drive was immediately suspended in the rea. The police officers were rushed to the nearby bbasi Shaheed Hospital but all seven of them were eclared dead on arrival. No health workers were njured in the attacks. The provincial police chief, llah Dino Khwaja, stated that the target this time as the police and not the health workers [5].

Haitian cholera outbreak—United Nations admits involvement

The United Nation’s recent admittance of its nvolvement in the Haiti cholera outbreak has ed to harsh criticism of the world body. Despite laiming immunity against legal action, it took ore than five years for the UN to accept that it layed a key role in bringing cholera to the region 1]. The first case of cholera was seen in Haiti in ctober 2010, following a devastating earthquake hat struck earlier in the year [2]. By December 010, 121,518 cases had been reported with the eath toll rising to 2591. Not only had the epidemic ffected all 10 provinces of Haiti, but had also by hen spread to the adjoining Dominican Republic nd Florida, United States [3]. Five years later, almost 10,000 people have died, nd hundreds of thousands have been affected y the disease, with 14,000 cases reported in 016 alone [2]. When investigated, two possible ypotheses arose, regarding how the bacteria, and onsequently the potentially life-threatening diarheal disease reached Haiti. The initial ‘environmental’ hypothesis claimed hat the virulent strain responsible for the epidemic ad previously existed in the waters around Haiti, nd the January 2010 earthquake had caused the acteria to contaminate the drinking water. DNA equencing of stool samples from Haitian patients upported this; studies revealed the presence of oth infectious and noninfectious environmental trains, but did not ascertain which of the two aused the disease [2]. The second hypothesis, the ‘peacekeeper’s ypothesis’, provided a more believable explanaion. The earthquake had attracted international id from many organizations, including the United ations, which sent troops to the region. The ast troop of peacekeepers had come from Nepal,

Telepsychiatry in Pakistan after natural disasters

Despite recent advances, access to mental health care is still restricted in some low-income and middle-income countries because of limited availability of health facilities in rural areas, reluctance to seek psychiatric help because of cultural considerations, and other factors. Therefore, there is an urgent need for innovative methods to deliver mental health services, particularly in remote areas. Telepsychiatry, which includes the use of video-based conferencing to deliver mental health services, has vast potential to bridge this gap. In Pakistan, where about 160 000 people experience mental health problems, and 34% of population is aff ected by anxiety and depression, telepsychiatry can ensure that high-risk patients receive timely help. Recently, telepsychiatry was used to treat post-traumatic stress disorder (PTSD) in a rural setting in northern Pakistan. The village of Charun Oveer experienced two consecutive natural disasters in 2015; it was hit by fl oods in March, followed by an earthquake measuring 7·5 on the Richter scale in October, which demolished 89 of the 140 houses in the region. Unsurprisingly, many people experienced psychological disturbances. Since the closest health-care facility was situated 3 h away by road, telepsychiatry was the only viable option for providing sustainable psychological and psychiatric treatment. The required facilities were set up by the medical corps arm of Karachi Relief Trust, an organisation specialising in disaster relief, headed by Dr Naseer Mehmood and Dr Nuzhat Faruqui. It was assisted by mental health experts who volunteered for the project. They diagnosed PTSD and other disorders among survivors, who reported a variety of symptoms including insomnia, nightmares, and fl ashbacks, using a quality of life scale. One of the authors (MHU) volunteered in the project and witnessed it fi rst-hand. Initially, two community-based sessions were held in which 160 people attended, with 60 men in one session and 100 women in the other session. The people of the village allowed the team to conduct all activities at the local community spiritual centre. These were a combination of visual, oral, and interactive sessions aimed at destigmatising and spreading awareness regarding mental health problems among the local population. After the initial sessions, translators were employed to further engage the local villagers. The villagers were taught breathing exercises, and art and music therapy was introduced at the community spiritual centre in the village. Additionally, 18 community members were given intense three-day training sessions as mental health workers; obtaining histories and screening the community members for anxiety, depression, and PTSD only. 500 adults were screened and 57 were diagnosed with symptoms of PTSD or depression. These were then shortlisted for the telepsychiatry sessions, and each patient was given a prearranged hour-long appointment with a trained psychiatrist at least once a week. The intervention was delivered to the patients in this manner for the following ten months after which the project came to a close. Outcomes for the project are not available as yet. While concrete evidence regarding effi cacy of telepsychiatry is still being assessed, it is definitely beneficial when in-person interaction between doctor and patient cannot occur. Telepsychiatry has great potential to deliver eff ective help to those who are isolated from expert mental health care, thereby reducing the treatment gap.

Sanitary Worker’s Death Unnerves Pakistan’s Health Care Ethics to the Core

Health care ethics is a sensitive domain, which if ignored, can lead to patient dissatisfaction, weakened doctor–patient interaction and episodes of violence. Little importance has been paid to medical ethics within undergraduate medical education in developing countries such as Pakistan. Three doctors in Pakistan are currently facing an official police complaint and arrest charges, following the death of a sanitary worker, who fell unconscious while cleaning a drain and was allegedly refused treatment as he was covered in sewage filth. The medical license of the doctors in question should be cancelled, if found guilty following a thorough investigation into the case. The ‘right to life’ has been universally assured by all moral, cultural and legal codes and no society can ever argue against the sacredness of a human life. It is quite clear that the aforesaid doctors’ actions are not only against the core principles of the physicians’ code, but also go against the doctrine of human rights. If serious efforts on an urgent basis are not made by the regulatory and governing bodies, one can definitely expect similar incidents for at least a few more decades before any noticeable change is seen.

Uterine Transplant: A Risk to Life or a Chance for Life?

Being inherently different from any other lifesaving organ transplant, uterine transplantation does not aim at saving lives but supporting the possibility to generate life. Unlike the kidneys or the liver, the uterus is not specifically a vital organ. Given the non-lifesaving nature of this procedure, questions have been raised about its feasibility. The ethical dilemma revolves around whether it is worth placing two lives at risk related to surgery and immunosuppression, amongst others, to enable a woman with absolute uterine factor infertility to experience the presence of an organ enabling childbirth. In the year 2000, the first uterine transplantation, albeit unsuccessful, was performed in Saudi Arabia from where it has spread to the rest of the world including Sweden, the United States and now recently India. The procedure is, however, still in the preclinical stages and several ethical, legal, social and religious concerns are yet to be addressed before it can be integrated into the clinical setting as standard of care for women with absolute uterine factor infertility.

Scientific publications and the curriculum vitae: A medical student's Achilles' heel?

With the number of hopeful students eager to surge ahead in the noble profession of medicine, increasing every day, the world of both academic as well as clinical medicine is fast becoming more competitive. Thanks to globalization, our world is far more interconnected than it ever was. Discoveries and breakthroughs are occurring right this minute and are being transmitted live the very next. This is an exciting time to be a part of the medical community. There is no limit, no barrier to what a person may achieve, albeit with untiring hard work and an unflagging determination.

Commotio cordis: A review

Commotio cordis is an increasingly reported fatal mechano-electric syndrome and is the second most common cause of sudden cardiac death in young athletes. It is most commonly associated with a sports-related injury, wherein, there is a high-velocity impact between a projectile and the precordium. By virtue of this impact, malignant arrhythmias consequently develop leading to the individual’s immediate demise, accompanied by a relatively normal post-mortem analysis. The importance of an autopsy remains paramount to exclude other causes of sudden death. With increasing awareness and reporting, survival rates are beginning to improve; however, prevention of the development of this condition remains the best approach for survival.

Pakistan: a transplant tourism resort?

The recent death of a Jordanian national, following an illegal kidney transplantation carried out by two local doctors in Lahore, Pakistan has once again highlighted the increasingly widespread illegal organ trade that has flourished in private hospitals in the country. It has been reported that other foreigners, including Omani, Saudi and Libyan nationals had also sought kidney transplants through the convicted doctors, who have been arrested along with their active accomplices, including a local anesthesiologist and paramedical staff while an investigation to arrest other doctors involved in this crime racket is underway. Organ trafficking was criminalized in Pakistan in 2007 by the Transplantation of Human Organs and Tissues Ordinance, followed by the Transplantation of Human Organs and Tissues Act 2010. This legislative revolution stemmed from a triad of influences; advocacy by local medical community, national media coverage spreading awareness of the exploitative nature of this transplant commercialism and reinforcement of the above via efforts of international medical bodies: the Transplantation Society and the WHO. Prior to this legislature, Pakistan was a destination for ‘transplant tourism’, with two-thirds of the 2000 kidney transplants performed on foreign nationals, by 2006. Although the incidence of illegal kidney transplants fell sharply before the 2007 ordinance, it began to rise again in the wake of weak implementation and corruption. Several factors contribute to the decreased effectiveness of Pakistan’s legislative changes. The desperation of susceptible populations such as illiterate and impoverished individuals, undocumented immigrants, prisoners, political or economic refugees and the bonded labor working in the agricultural sector (Pakistan’s economic backbone), compels such unfortunate individuals to donate their kidneys in order to make ends meet, with very little priority given to the long term health effects of organ removal. Furthermore, with the local nature of these undercover transplantations carried out in private hospitals, any attempt to shut down this practice via law enforcement, encounters strong resistance from physicians and hospital owners involved in the lucrative organ trade as well as from the feudal system that encourages bound labor and peonage. Not only does illegal organ trade risk the lives of both donor and recipient but is also tarnishing Pakistan’s international reputation, since the country is currently a signatory of Declaration of Istanbul Custodian Group (DICG) which works under the WHO to prevent transplant tourism and organ trafficking. Suo-moto notice of this matter was taken by the Supreme Court in August 2016. A viable alternative to this problem is to increase awareness and encourage deceased organ donation, by devising various programs, among the general public, the majority of which is either unaware of or else has religious reservations regarding the concept. Unfortunately, despite having a population of around 200 million, Pakistan has only seven deceased organ donors on record, the most well known being the philanthrophist Abdul Sattar Edhi. The onus of responsibility lies upon the government to push forward this option, which will not only put an end to the illegal kidney trade but also serve to benefit the thousands of Pakistani citizens suffering from end stage renal failure annually.